Archived: The White House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Quality frameworks were not effective in identifying shortfalls in the care people received or gaps in people’s care records. We found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights to be free from abuse and neglect. We found the leadership team was not always open and transparent with stakeholders and CQC in relation to all allegations of abuse. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk.

The provider failed to ensure the needs of those living with dementia were met. We were told by staff that all people were required to choose their meals the day before. This is not good practice for people living with dementia and disregarded the right of anybody to change their mind about what food they may wish to eat.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Of the management in the service 1 person told us, “The staff here are generally good- But the manager just comes around and shouts. We call her the Sargeant Major.” Leaders had failed to ensure staff were equipped to undertake their role. There was a lack of robust training and supervision. Staff had only been given access to handheld devices which meant that updating care records was delayed as they were having to share them. Staff were having to access dangerous, steep and degrading stairs down to the cellar where people’s food was stored. The manager said of this, “It does need looking at. It absolutely does. But there is nowhere else for us to put the food.” However, this was a large home with empty rooms that could have been used for this, yet leaders had not taken action to address this.

Quality assurance processes were not consistently implemented, and the delegation of responsibilities was unclear, resulting in a lack of clarity about who held responsibility and accountability for key areas of the service. During the day we observed a lack of leadership on the floor, it was not clear who was the senior in charge, and we frequently saw 1 member of staff just standing in the room waiting for direction. When the manager was present in the communal areas they did not interact with people and did not intervene when they observed 1 person had been incontinent.

During the inspection the provider’s representative told us they were aware of significant shortfalls in the quality of the service, the management team, and the standard of auditing and monitoring. They stated that they had known this for several months, and despite knowing this, had failed to address this with the manager or staff team. This failure has had a detrimental and serious impact on people’s safety, and people have suffered avoidable harm.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There had not been a registered manager at the service since July 2024 which is a legal requirement. We also identified that notifications that were required to be sent to the CQC were not always submitted.

Overall, governance arrangements failed to provide effective oversight, ensure accurate auditing, or prompt appropriate follow-up actions. Key safety and quality processes were not embedded, leaving systemic weaknesses and ongoing risks to people’s safety and care. Leaders had failed to make sustain the improvements since the previous inspection to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users. We found there had been limited identification, assessment or mitigation of individual risks. Staff did not have guidance in how to manage people’s risks when providing their care.

Although a number of audits were taking place, these were not robust and often had very little detail on any areas for development or improvement. The provider told us they also had concerns with audits not identifying areas for improvement however there was a lack of robust action to follow this up.

The providers electronic care system was able to produce reports to identify the safety and quality of care, however these were not being utilised. We were able to identify using this system, the lack of oral hygiene, personal care and the lack of fluid intake. However, none of this had been identified by the leadership team. This meant they could not be assured that all areas of service delivery were monitored and that actions were taken to improve poor practice.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. Leaders lacked an understanding of when to escalate concerns to visiting professionals and when they did, they were not always recording the advice that had been given. One health professional fed back where 1 person had fallen, “There was a delayed escalation (to seek medical attention).” Another fed back, “Staff don’t seem to be following our guidance or following the correct process to escalate their concerns.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The lack of effective systems, governance and management meant there was no drive to improve the safety of the care and support being delivered. We did some improvements to the aesthetic of the building. However, people continued to have poor experiences of care, with a lack of action to improve people’s outcomes. The provider did not have oversight of how care was delivered. This meant opportunities to analyse and review accidents and incidents for themes and trends did not occur. Effective learning was therefore not identified or shared with staff. This meant improvements to the service and the care people received were not always considered or implemented.